Many insurers use radiology reports of flexion-extension radiographs to determine eligibility for lumbar fusion. Traditionally, most surgeons rely on flexion-extension radiographs to evaluate for the presence or absence of anterior-posterior lumbar instability as measured by the difference in slip percentage ( 12, 16, 17). Instability in lumbar spondylolisthesis has been characterized by a number of radiographic findings such as slip displacement, sagittal disc angle, disc height, facet joint orientation, the presence of facet effusion, and severity of degenerative change ( 12- 15). On the other hand, fusion can be associated with complications (e.g., higher risk for longer hospital stay, longer operative time, increased blood loss, adjacent segment disease) and higher costs, and may not be necessary for those without lumbar instability ( 8- 11). In the appropriate patient, fusion has been shown to successfully halt the progression of spondylolisthesis, reduce pain, and improve patient-reported outcomes when compared to decompression alone ( 4- 7). The decision regarding whether or not to fuse most often depends on the surgeon’s assessment of lumbar segmental stability. However, there continues to be considerable debate among spine surgeons regarding the optimal surgical management of lumbar stenosis in the presence of spondylolisthesis, namely decompression alone versus decompression and fusion ( 2- 4). Lumbar spondylolisthesis is a common cause of low back pain and radicular leg pain, which often warrants operative intervention ( 1). Keywords: Spondylolisthesis ventral instability anterolisthesis flexion-extension lumbar (FE lumbar) radiographic lumbar instability These changes are not dependent on age or gender. The FS and NS comparisons also show greater slip percentage differences at higher slip grades, but not at different lumbar levels. No statistically significant correlation was found between SP and disc angle for all radiographic views.Ĭonclusions: Comparing standing lateral and flexion X-rays with supine MRIs provides higher sensitivity to assess instability than standard flexion-extension radiographs. The slip percentage (SP) difference was significantly highest in the flexion-supine (FS) (5.7 mm, 12.3%) and neutral standing-supine (NS) (4.3 mm, 8.7%) groups, both of which were significantly higher compared with the flexion-extension (FE) group (1.8 mm, 4.5%, P8% was observed more frequently in FS (79.5%) and NS (52.6%) groups compared with FE group (16.7%, P<0.001). There was good intra- and inter-rater reliability agreement between measured values on the presence of instability. The mean age was 57.3☑6.7 years and 66% were female. Results: All 39 patients with symptomatic, single-level lumbar spondylolisthesis were identified. Patients were excluded if they had prior lumbar surgery, missing radiographic data, or if the time between X-rays and MRI was >6 months. Routine standing lumbar X-rays (neutral, flexion, extension) and supine lumbar MRI (sagittal T2-weighted imaging sequence) were performed. Methods: Consecutively collected adult (≥18 years old) patients with symptomatic single-level lumbar spondylolisthesis were reviewed from a two-surgeon database from 2015 to 2019. Policy of Dealing with Allegations of Research Misconductīackground: Generally, most spine surgeons agree that increased segmental motion viewed on flexion-extension radiographs is a reliable predictor of instability however, these views can be limited in several ways and may underestimate the instability at a given lumbar segment.Policy of Screening for Plagiarism Process.
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